Documente Academic
Documente Profesional
Documente Cultură
DOI 10.1007/s00134-017-4891-0
ORIGINAL
Abstract
Purpose: The relative merits of immediate extubation versus terminal weaning for mechanical ventilation withdrawal
are controversial, particularly regarding the experience of patients and relatives.
Methods: This prospective observational multicentre study (ARREVE) was done in 43 French ICUs to compare
terminal weaning and immediate extubation, as chosen by the ICU team. Terminal weaning was a gradual decrease
in the amount of ventilatory assistance and immediate extubation was extubation without any previous decrease in
ventilatory assistance. The primary outcome was posttraumatic stress symptoms (Impact of Event Scale Revised, IES-R)
in relatives 3months after the death. Secondary outcomes were complicated grief, anxiety, and depression symptoms
in relatives; comfort of patients during the dying process; and job strain in staff.
Results: We enrolled 212 (85.5%) relatives of 248 patients with terminal weaning and 190 relatives (90.5%) of 210
patients with immediate extubation. Immediate extubation was associated with airway obstruction and a higher
*Correspondence: jean.reignier@chunantes.fr
68
Service de Mdecine Intensive Ranimation, Centre Hospitalier
Universitaire Hotel-Dieu, 30 Bd. Jean Monnet, 44093Nantes Cedex 1,
France
Full author information is available at the end of the article
210 patients had immediate extubation 248 patients had terminal weaning
199 patients died in the ICU 248 patients died in the ICU
190* relatives completed questionnaires with a 212* relatives completed questionnaires with a
psychologist: psychologist:
182 relatives 3 months after the death 208 relatives 3 months after the death
(IES-R, HADS, and satisfaction questionnaire) (IES-R, HADS, and satisfaction questionnaire)
168 relatives 6 months after the death (HADS and ICG) 186 relatives 6 months after the death (HADS and ICG)
152 relatives 12 months after the death (IES-R, HADS, 159 relatives 12 months after the death (IES-R, HADS,
and ICG) and ICG)
Fig.1 Study flowchart. ICU intensive care unit, IES-R Impact of Events Scale-Revised, HADS Hospital Anxiety and Depression Scale, ICG Inventory of
Complicated Grief. *For each patient, a single relative completed the questionnaires. Relatives who did not respond to phone calls 3months after
the patients death were called again 3months later. If they did not respond then, they were not called 12months after the death. Those relatives
who completed questionnaires 3months after the death but did not answer the phone calls 6months after the death were called 12months after
the death and invited to complete questionnaires
Considerable variation exists in practices for mechani- methods is mainly a matter of opinion. In the current large
cal ventilation withdrawal in the ICU [11, 12]. Few data are study under the conditions of everyday practice, immedi-
available for determining whether one method is superior ate extubation and terminal weaning were preferred by
over the other. Consequently, the choice between the two nearly identical proportions of ICU staff; however, the
Table1 Characteristics ofthe patients andenrolled relatives
Patient characteristics atadmission Immediate extubation Terminal weaning p value
n=210 n=248
ICU stay before decision (days), median [IQR] 6.0 [3.0; 12.0] 8.0 [4.0; 16.5] <0.001
SOFAc, meanSD 84 94 <0.001
RASS scored, meanSD 42 41 0.02
Behavioural Pain Scale scoree 2.51.1 2.40.8 0.29
Treatments, n (%)
Vasoactive drugs, n (%) 34 (16.2) 92 (37.1) <0.001
Dialysis, n (%) 15 (7.1) 28 (11.3) 0.13
FiO2, meanSD 3818 5223 <0.001
PEEP (cmH2O), meanSD 52 63 <0.001
PaO2/FiO2, meanSD 26496 209106 <0.001
Table1 continued
Relatives characteristics n=190 n=212
between-group differences in admission diagnoses sug- Symptomatic airway obstruction and gasps were more
gest a preference for immediate extubation in comatose common and the mean BPS score was higher in the
patients and for terminal weaning in patients with res- immediate extubation group. This finding can be ascribed
piratory failure. In contrast to previously stated opinions, to airway compromise directly related to removal of the
in our observational study, immediate extubation was not endotracheal tube with subsequent obstruction by the
associated with a greater burden on the relatives com- tongue and/or inability to remove secretions. Another
pared to terminal weaning [18]. Importantly, satisfaction factor may be underuse of analgesics and sedatives in
was very high among relatives and staff, with no difference patients undergoing immediate extubation. Higher doses
between methods, except in the residents. Thus, our study of opioids and sedatives were used in the patients under-
suggests that, for the relatives, the two methods may result going terminal weaning, in whom previous respiratory
in similar experiences, provided the staff members are well and/or multi-organ failure was more severe than in the
trained in, and comfortable with, the method they apply. immediate extubation group. Interestingly, time to death
Table2 Assessment ofthe dying process afterthe decision towithdraw mechanical ventilation
Immediate extubation Terminal weaning p value
(N=210) (N=248)
Just before extubation or the first change in ventilator settings for terminal weaning
Relatives invited to stay in the patients room during extubation or the <0.001
first change in ventilator settings for terminal weaning, n (%)
Accepted 56 (27.5) 114 (46.9)
Refused 97 (47.5) 62 (25.5)
Not extended 51 (25.0) 67 (27.6)
People in the patients room, n (%)
Senior physician 164 (79.6) 218 (89.3) 0.004
Resident 82 (39.8) 80 (32.9) 0.13
Nurse 205 (99.5) 188 (77.4) <0.001
Nursing assistant 91 (44.2) 41 (16.9) <0.001
At least one relative 47 (22.8) 100 (41.2) <0.001
Religious representative 2 (1.0) 7 (2.9) 0.15
Palliative care team member(s) 0 (0.0) 1 (0.4) 0.36
During the dying processa
Patients vital signs
Maximal respiratory rate (/min), meanSD 2810 269 0.12
Airway obstructionb, n (%) 138 (65.7) 128 (51.6) 0.002
Gasping, n (%) 94 (44.8) 50 (20.2) <0.001
Highest Behavioural Pain Scalec score, meanSD 2.91.4 2.50.9 <0.001
Treatments received
Opioids, n (%) 169 (80.5) 229 (92.3) <0.001
Highest administration rate (mg/h), meanSD 12.418.1 23.331.5 <0.001
Hypnotic drugs, n (%) 154 (73.3) 219 (88.3) <0.001
Highest administration rate (mg/h), meanSD 23.049.6 40.286.8 0.02
Neuromuscular blocking agents, n (%) 4 (1.9) 41 (16.5) <0.001
At time of death
Time to death from extubation or first change in ventilator settings for 2.7 [0.4; 10.9] 3.9 [1.0; 17.8] 0.68
terminal weaning (h), median [IQR]
Death in the ICU, n (%) 199 (94.8) 248 (100.0) <0.001
Door of the room closed, n (%) 128 (68.1) 172 (72.6) 0.31
People in the room, n (%)
Senior physician 62 (32.8) 87 (36.0) 0.49
Resident 32 (17.0) 47 (19.5) 0.51
Nurse 135 (72.2) 156 (64.5) 0.09
Nursing assistant 63 (33.7) 62 (25.8) 0.08
At least one relative 106 (55.2) 139 (57.7) 0.61
Religious representative 2 (1.1) 4 (1.6) 0.70
Palliative care team member(s) 1 (0.5) 0 (0.0) 0.26
The respiratory rates and Behavioural Pain Scale scores in the table are the highest values observed during the dying process
ICU intensive care unit
a
The dying process was defined as starting at extubation in the immediate extubation group or at the first change in ventilator settings in the terminal weaning
group and ending at death
b
Patients with at least one episode of airway obstruction were recorded. Airway obstruction was assessed using an airway obstruction scale (1, none; 2, mild, without
clinical consequences; 3, with one sign of respiratory failure [respiratory rate >30, thoraco-abdominal swing, flaring of the nostrils, or diaphoresis]; and 4, airway
obstruction with two or more signs of respiratory failure)
c
The Behavioural Pain Scale measures pain in critically ill patients treated with mechanical ventilation [20]. Three items (facial expression, upper limb movements, and
compliance with mechanical ventilation) are scored from 1 to 4. In the current study on withdrawal of mechanical ventilation, the item compliance with mechanical
ventilation was not recorded. Therefore, values could range from 2 (no pain) to 8 (severe pain)
Table3 Assessment ofposttraumatic stress syndrome, complicated grief, anxiety, anddepression inrelatives afterthe decision towithdraw mechanical venti-
lation
3months 6months 12months
Univariate analysis Multivariate analysis Univariate analysis Multivariate Univariate analysis Multivariate analysis
analysis
Extubation Terminal P P Extuba- Terminal p p Immediate Terminal p p value
N=182 weaning value value tion weaning value value extubation weaning value
N=208 N=186 N=152
N=168 N=159
a
IES-R , meanSD N=158d
Total score 30.516.2 31.918.1 23.617.1 25.016.4
Estimated 1.4 [4.8; 2.0] 0.43 1.9 [5.9; 2.1] 0.36 1.4 [5.1; 2.3] 0.46 0.8 [5.2; 3.6] 0.72
difference
[95% CI]
Intrusion 14.87.5 15.77.7 11.47.7 12.77.2
Estimated 0.9 [2.4; 0.6] 0.25 1.0 [2.8; 0.8] 0.26 1.3 [3.0; 0.3] 0.12 1.2 [3.2; 0.8] 0.24
difference
[95% CI]
Hyperarousal 5.85.5 5.85.9 5.15.3 5.25.1
Estimated 0.0 [1.2; 1.1] 0.89 0.1 [1.4; 1.3] 0.93 0.1 [1.2; 1.1] 0.97 0.5 [0.9; 1.9] 0.46
difference
[95% CI]
Avoidance 9.97.1 10.47.2 7.16.8 7.26.8
Estimated 0.5 [1.8; 1.0] 0.57 0.8 [2.5; 0.9] 0.37 0.1 [1.6; 1.5] 0.94 0.1 [2.0; 1.7] 0.88
difference
[95% CI]
Presence of 84 (46.2) 89 (42.8) 40 (26.3) 50 (31.6)
PTSD-
related
symptoms,
n (%)
Odds ratio 1.15 [0.77; 1.71] 0.50 1.18 [0.70; 1.99] 0.54 0.77 [0.47; 1.26] 0.30 0.86 [0.44; 1.67] 0.64
[95% CI]
ICGb, meanSD
Total score 22.414.6 23.715.0 21.016.1 19.614.2
Estimated 1.3 [4.4; 1.8] 0.42 0.0 [3.6; 0.99 1.4 [2.0; 4.8] 0.42 1.6 [2.3; 5.6] 0.42
difference 3.5]
[95% CI]
Presence of 58 (34.5) 80 (43.0) 55 (36.2) 54 (34.0)
compli
cated grief
symptoms,
n (%)
Odds ratio 0.70 [0.45; 1.07] 0.10 0.67 [0.37; 0.19 1.10 [0.69; 1.76] 0.68 1.07 [0.57; 2.02] 0.83
[95% CI] 1.22]
Table3 continued
3months 6months 12months
Univariate analysis Multivariate analysis Univariate analysis Multivariate Univariate analysis Multivariate analysis
analysis
Extubation Terminal P P Extuba- Terminal p p Immediate Terminal p p value
N=182 weaning value value tion weaning value value extubation weaning value
N=208 N=186 N=152
N=168 N=159
HADSc, meanSD
Total score 15.38.6 14.29.1 12.88.4 12.48.3 11.78.1 10.97.3
Estimated 1.1 [0.7; 2.9] 0.22 0.8 [1.2; 2.8] 0.42 0.4 [1.3; 2.2] 0.62 1.7 [0.4; 0.11 0.8 [0.9; 2.5] 0.35 1.4 [0.7; 3.4] 0.19
difference 3.7]
[95% CI]
Anxiety 8.24.6 7.94.9 7.64.7 7.54.8 7.34.5 6.94.2
Estimated 0.3 [0.7; 1.3] 0.55 0.2 [0.9; 1.3] 0.75 0.1 [-0.8; 1.2] 0.73 0.8 [0.4; 0.19 0.4 [0.6; 1.4] 0.42 0.6 [0.6; 1.8] 0.30
difference 2.0]
[95% CI]
Depression 7.15.3 6.25.5 5.25.0 4.94.8 4.54.6 4.04.2
Estimated 0.8 [0.3; 1.9] 0.13 0.7 [0.6; 1.9] 0.29 0.3 [0.8; 1.3] 0.61 0.9 [0.3; 0.15 0.5 [0.6; 1.4] 0.41 0.8 [0.4; 2.0] 0.22
difference 2.1]
[95% CI]
Presence of 76 (41.8) 87 (41.8) 70 (41.7) 73 (39.2) 50 (32.9) 49 (30.8)
anxiety
symptoms,
n (%)
Odds ratio 0.99 [0.67; 1.45] 0.99 1.01 [0.60; 1.69] 0.97 1.10 [0.72; 1.69] 0.64 1.26 [0.72; 0.42 1.10 [0.68; 1.77] 0.69 1.26 [0.67; 2.39] 0.48
[95% CI] 2.20]
Presence of 72 (39.6) 63 (30.3) 42 (25.0) 41 (22.0) 26 (17.1) 21 (13.2)
depression
symptoms,
n (%)
Odds ratio 1.50 [0.99; 2.29] 0.06 1.53 [0.89; 2.64] 0.13 1.18 [0.72; 1.93] 0.51 1.68 [0.87; 0.12 1.36 [0.73; 2.53] 0.34 1.51 [0.68; 3.38] 0.32
[95% CI] 3.23]
IES-R Impact of Events Scale-Revised, 95% CI 95% confidence interval, PTSD posttraumatic stress syndrome, ICG Inventory of Complicated Grief, HADS Hospital Anxiety and Depression Scale
a
Total scores on the Impact of Events Scale-Revised (IES-R) can range from 0 (no PTSD-related symptoms) to 88 (severe PTSD-related symptoms). A total IES-R score >32 indicates PTSD-related symptoms. The intrusion
subscore can range from 0 to 32, the hyperarousal subscore from 0 to 24, and the avoidance subscore from 0 to 32
b
The Inventory of Complicated Grief (ICG) score can range from 0 (no complicated grief ) to 76. Scores >25 indicate complicated grief
c
The Hospital Anxiety and Depression Scale score can range from 0 (no anxiety or depression) to 42 (severe anxiety and depression). Anxiety or depression subscores >8 indicate clinically meaningful symptoms of
anxiety or depression, respectively
d
One relative had six unanswered items and was not included in the analysis
Table4 Job Strain Scores ofnurses, nursing assistants, senior physicians, andresidents
Nurses p Nursing assistants p Senior physicians p Residents p
Multivariate analysis